BANTAO Journal 2010; 8 (2): 85-87

BJ
BANTAO Journal
Case Report

Pregnancy in End-stage Renal Disease Patients on Long-term

Hemodialysis: Two Case Reports
Selim Gjulsen1, Stojceva-Taneva Olivera1, Tozija Liljana1, Gelev Saso1, Adamova Gordana2,
Gerasimovska-Kitanovska Biljana1 and Sikole Aleksandar1
1

University Clinic of Nephrology, 2University of Obstetrics and Gynaecology, Medical Faculty, University
Sts. Cyril and Methodius Skopje, Republic of Macedonia
Abstract
Although still uncommon, pregnancy in haemodialysis (HD)
patients does occur and frequency has been increased in
the past 20 years. But unfortunately, the rates for premature delivery, neonatal death, maternal hypertension, and
preeclampsia in the pregnant HD patient are much higher than in the general population. Infants are often born both
prematurely and small for gestational age. We report here
two cases of pregnancy in women on long-term HD, one
successfully and the other unsuccessfully managed, despite the same treatment strategy. Case 1 was a 43-year-old
female patient, 10th gravida, after six years of maintenance
HD whose pregnancy was successfully managed up to the
33rd week of gestation with a delivery of a healthy boy weighing 2,100 g. Case 2 was a 32-year-old female patient, 2nd
gravida, after five years of maintenance HD, whose pregnancy ended in spontaneous abortion with intrauterine death
at week 19 of gestation. Maternal hypertension and anemia contributed partly to the unsuccessful outcome.
A successful pregnancy in HD patients requires multidisciplinary management, but considering the previous nephrological/prenatal/gynaecological/obstetric recommendations, many open questions remain when it comes to the best
treatment and management of pregnancy in these women.
Key words: haemodialysis, pregnancy, anaemia,
hypertension

___________________________________________
Introduction
In 1971 Confortini et al. [1] reported the first successful
pregnancy in a 35-year-old woman on chronic HD. Over
time, the outcome of pregnancies in patients on HD has markedly improved, from only 23% live births during the 1980s
based on a report from the European Dialysis and Transplant Association [2], to 50100% (overall 76.25%) surviving infants from the systematic reviews in the recent
literature (2000 through 2008) [3]. The results of 90 preg-

nancies reported in the new millennium confirm that pregnancy is still a challenge but also a possibility [3,4]. Nevertheless, fetal mortality in pregnant women on HD is still
much higher than in the general population [4]. Polyhydramnios-possibly due to fetal solute diuresis caused by high
placental blood urea nitrogen (BUN) concentration, maternal hypertension and premature rupture of the fetal membranes are suspected of causing premature delivery [5]. Shifts in acute fluid volume, electrolyte imbalance, and hypotension could also contribute to the major dialysis-related complications resuling in impairment of the uteroplacental circulation [6]. There are some recommendations for HD management of pregnant patients to improve
outcomes, but systematic nephrological and prenatal/ gynaecological/obstetric treatment approach cannot be found
in the literature. We report here two cases of pregnancy in
women on long-term HD, one successfully and the other
unsuccessfully managed.
Case presentation
Case report 1
A 43-year-old female patient, 10th gravida with three living
offsprings (1988, 1990, 1993 year) and a history of five
abortions before 1988. During the first trimester of her
9th pregnancy (may1996), she developed placental abruption with peripartal haemorrhage, complicated with fetal
death and acute renal failure. Bilateral renal cortical necrosis was documented in a contrast-enhanced CT scan in
this patient who presented with anuria and remained dependent on dialysis. Renal biopsy was not done due to patient's refusal and she was diagnosed as a case of ESRD
in July 1996. She remained on maintenance HD three times a week, with no significant problems.
After six years on maintenance HD (in 2002), she presented with abdominal distension and amenorrhea and was
found to be 16 weeks pregnant, diagnosed by serum HCG
testing and pelvic ultrasound, but amniocentesis was not
done due to patient's refusal. The patient was dialyzed with

________________________
Correspondence to:
Gjulsen Selim, University Clinic of Nephrology, University Sts. Cyril and Methodius, Vodnjanska
17, 1000, Skopje, R. Macedonia; Phone: ++ (389) 2 3147 191; E-mail:gjulsen_selim@yahoo.com

Pregnancy in ESRD

86

bicarbonate dialysate and low-flux polysulfone F6HPS

membrane with 1.3m2 effective surface dialyzers that were
not reutilized. The HD schedule was increased during pregnancy to 4 hours 4 times weekly between the 16th to the
23rd week of gestation, 4 hours 5 times weekly between
the 24th to the 28th week of gestation and 4 hours 6 times
weekly after the 28th week of gestation. As a consequence, her pre-dialysis blood urea levels decreased from 22.1
mmol/l (20th week), 17.7 mmol/l (24th week), 15.6 mmol/l
(28th week) to 14.4 mmol/l at the end of pregnancy, and
serum creatinine dropped from 622 mol/l to 455 mol/l.
As part of her medication, the required dose of erythropoietin (Epo) was increased from a mean weekly dose of
6000 units to 10000 units during pregnancy, but her haemoglobin level ranged between 90 and 72g/l. Iron was also
increased from 50mg/weekly to 100 mg/weekly, but transferrin saturation was 22.8% (24th week) and 15.9% (28th
week). Blood pressure was controlled by minimal dose of
alpha methyldopa of 125mg two times a day, and blood
pressure using the ambulatory blood pressure monitoring was 119/76 mmHg (20th week) and 114/72 mmHg
(28th week). She also received calcium carbonate, 1500
mg/day as a phosphate binder, multivitamins and folic acid.
On the 33rd week of gestation, the patient had a caesarean section delivery of a live boy weighing 2,100 g. After
delivery, the mother returned to the schedule of three dialyses per week. The patient and her boy have remained healthy eight years after.
Case report 2
A 32-year-old female patient, 2nd gravida without living
offsprings. ESRD was a result of focal segmental glomerulosclerosis proven by renal biopsy in 1996. Her first pregnancy (1997) was complicated by pre-eclamsia with abortion in the 28th week and as her renal function continued
to deteriorate, maintenance HD was initiated in April 1997
(three sessions a week). In the first two years of HD she
was with poor volume control and hypertensive, depressive, and developed pulmonary tuberculosis that resolved successfully within 6 months. After the first two years
of maintenance HD, she remained normotensive and had a
regular dialysis course.
Five years after the onset of maintenance HD (2002), the
patient informed the nephrologist that she might be pregnant. Gynecological and ultrasound examination confirmed
the presence of a live fetus at 13 weeks of gestation.
From then onwards, HD prescription was changed to 4 days a week and 5 days a week after 16 weeks of pregnancy, with duration of 4 hours per session. The patient was
dialyzed by using bicarbonate dialysate (with Enoxaparin sodium as anti-coagulant) with low-flux polysulfone
F6HPS membrane (1.3m2 effective surface). As expected, Epo and iron requirements were increased during her
pregnancy (Epo, from a weekly dose of 6000 units, to a
mean of 10.000 units and iron, from 50mg to 100 mg iv
once every week), but her haemoglobin level ranged between 81 g/l (14th week) and 65 g/l (16th week), and transferrin saturation between 15.2% and 13.6%, thus requiring
additional treatment of two units of red blood cells in the

17th week. Hypertension remained of concern during the

pregnancy, and she was treated with alpha methyldopa,
250 mg three times a day, between the 13-14th week of
gestation with a dose increase over the next week up to 1500
mg/day. Blood pressure using the ambulatory blood pressure monitoring was 135/91mmHg (14th week) and 156
/103mmHg (17th week). Interdialytic weight gain reached
no more than 2.0 kg. She, also, received calcium carbonate
1500 mg/day as a phosphate binder, multivitamins and
folic acid. She was intensively followed by the nephrologist and obstetrician, but nevertheless, the pregnancy ended in spontaneous abortion with intrauterine death at week 19 of gestation. After the delivery, the mother returned to the previous treatment strategy of three dialyses per
week and within the following eight years she had no significant problems.
Discussion
It has been shown that the prognosis for successful conclusion of pregnancy is better for patients who started HD
after initiation of pregnancy as compared to those who
conceived after starting HD (73.6% and 40.2%), respectively [4]. Our article reports cases representing patients who
conceived long after starting HD (case 1-after six years, case 2-after five years).
Most published papers report that increasing HD hours
improves pregnancy outcomes, specifically with respect
to gestational age, birth weight, and infant survival [4,7]. In
the largest study to date, the Registry for Pregnancy in Dialysis Patients reported the better infant survival in women
who received dialysis20 hours per week [4]. By 2002,
there were enough data available to say that 75% of infants would survive if dialysis was increased to 20 or more
hours per week, but that smaller increases in dialysis time were not beneficial [8]. Increasing dialysis dosage reduces predialysis BUN levels and intensified ultrafiltration
may reduce the occurrence of polyhydramnios, thus lower the risk of premature labour and rupture of membranes
in the later stages of pregnancy. Recommendations regarding the dialysis prescription for the pregnant woman on
HD suggest maintaining predialysis BUN concentration
of 50 mg/dl (17.85 mmol/l) is an appropriate goal [5].
Asamiya et al. showed that a birth weight equal to or greater than 1500g, or a gestational age equal to or exceeding 32 weeks corresponded to BUN levels of 48-49mg
/dl (17.14-17.49mmol/l) or less [9]. In our case 1, we gradually increased the number of the weekly dialysis sessions and the mean pre-dialysis BUN was maintained at
22.1 mmol/l, 17.7 mmol/l, 15.6 mmol/l and 14.4 mmol/l
respectively during pregnancy, which may have contributed in part to the successful outcome
Anaemia and hypertension (HTA) are the most frequent
maternal complications observed in the HD population during pregnancy and require intensive management. Recommendations for anaemia management of the pregnant
HD patients suggest that Epo doses need to be increased
by approximately 50% in order to maintain target haemoglobin levels of 1011 g/dl. The reason for the higher Epo
doses is unknown, but increased vascular volume with sub-

Gj. Selim et al.

sequent hemodilution and possibly erythropoietin resistance (due to enhanced cytokine production) during pregnancy may contribute to it [5]. New implications regarding the link between anaemia and pregnancy come from
studies in rats, which suggest a possible suppressive effect
of endogenous estradiol on erythropoietin induction through iron restoration [10]. This is not consistent with our observation, because, despite the increase of Epo doses for
approximately 60% in both cases, the haemoglobin levels
were below 90 mg/l, especially in case 2, which may have resulted partly to the unsuccessful outcome.
Common maternal complications observed in HD population during pregnancy include HTA, occurring in 4280% of these women and polyhydramnios [11]. The pathogenesis of maternal HTA in HD patients is complex, but
hypervolemia and inappropriate elevated total peripheral
resistance are likely central to the refractory nature of this
comorbid condition. Common to both HTA in ESRD and
preeclampsia is the impairment in vascular responsiveness [12]. Antihypertensive medications are often required
to maintain maternal diastolic blood pressure in the 8090 mmHg range. The mainstays of treatment are methyldopa, B-blockers, and hydralazine [5]. The patient in case
1 with successful delivery remained normotensive on minimal dose of antihypertensive medications and intensified
dialysis throughout pregnancy. However, in the other case
2, HTA was difficult to control during pregnancy despite
the maximum dose of methyldopa and increased dialysis
frequency, which most probably, at least partly contributed
to the unsuccessful outcome. Haemoglobin level in case
2 was not achieved to the levels recently recommended
for pregnant HD patients because of the risk to further
increase her high blood pressure with higher doses of
Epo [6]. The occurrence of HTA with Epo treatment is
thought to be secondary to the increase in red blood cell
mass, but the mechanism of HTA in this setting is
probably multifactorial. However, studies on HTA among
pregnant HD patients are lacking.
Several large surveys confirmed that infants born to women on HD are usually premature, with an average gestation of 32 week [3-5). According to the article by Hou,
82% of babies born to HD patients reported to the registry were born before term and 18% were born before 28
week of gestation with the mean gestational age of 29.5
weeks for women dialyzed less than 20 h/wk and 34 weeks for women dialyzed more than 20 h/wk. [8]. In contrast,
Baua et al. show that the mean gestational age in nocturnal
home hemodialysis (NHD) cohort was 36weeks, but what
potential advantages may NHD offer to improve pregnancy outcomes is unknown [12]. Our finding in case 1 is
in agreement with earlier reports regarding gestational age
since we failed to prolong gestational age beyond 32 weeks.
We reported on two cases of pregnancy in women on longterm HD who had different outcomes despite the same

87

management: successful in a 43-year-old female patient

in her 10th pregnancy and unsuccessful in a 32-year-old
female patient in her 2nd pregnancy. Maternal hypertension and anaemia contributed in part to the unsuccessful
outcome in case 2.
Conclusions
In conclusion, our case reports illustrate that following the
recommendations for dialysis management in pregnant women may result in successful outcome, but only an international registry of pregnancies in HD patients will help answer the many open questions on the best management of
pregnancy in HD women.
Conflict of interest statement. None declared.

References
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